Lead, Care Coordination -Orlando Health Watson Clinic Lakeland Highlands Hospital-Lakeland, FL

Orlando Health•Lakeland, FL

About The Position

Collaborates with the assigned care coordination team to include clinical support, guidance, and educational direction while also identifying patients most likely to benefit from care coordination services to include assessing patients’ risk factors, the need for care coordination, clinical utilization management, and preventative care services. Opening Summer 2026 at 4000 Lakeland Highlands Road, Lakeland, FL. The Orlando Health System of Care includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts, Central Alabama and Puerto Rico. Collectively, our dedicated team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Join us! Combining the collective strengths of two powerhouse organizations, Orlando Health and the high-quality physicians at Watson Clinic are expanding access to award-winning specialty care for patients in Polk County and beyond. Opening in summer 2026, Orlando Health Watson Clinic Lakeland Highlands Hospital – a state-of-the-art, seven-story, multi-specialty hospital – will serve as a vital 550,000 square-foot healthcare hub offering: 300+ inpatient beds and 69 emergency and observation beds 11 operating rooms and four cardiac interventional suites Dedicated labor and delivery services – including a neonatal intensive care unit (NICU) that will debut shortly after the hospital opens Comprehensive cardiovascular, neurology, and oncology services Advanced surgical procedures Join us in shaping the future of healthcare in Polk County as part of the Orlando Health Watson Clinic Lakeland Highlands Hospital opening team and share in the privilege of saying you were there from the very beginning. Benefits Beyond the Expected Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions. “Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.

Requirements

Graduate of an approved school of nursing (RN), or a Master’s degree in Social Work (MSW), Mental Health (MHC) or Marriage and Family Therapy (MFT) from an accredited program.
Florida RN license required and maintained current if graduated from an approved school of nursing. BLS/Healthcare
Provider certification required within 90 days of hire.
Two (2) years of related healthcare experience and/or supervisory experience in the community with an emphasis on the population to be served in the assigned area.

Responsibilities

Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory care/outpatient) to ensure integrated delivery across all settings to include the facilitation comprehensive discharge planning (in the hospital) and follow-up care (as an outpatient).
Develops an effective working relationship with the Licensed Mental Health Counselors/ Social Workers and the UR nurses to engage the patient/family to collaborate, advocate and problem solve, and to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
Assists in collaboration with the assigned team to identify patients most likely to benefit from care coordination services to include assessing the patient's risk factors and needs for care coordination, clinical utilization management services, and preventative services.
Serves as mentor to care coordination team through guidance, education, and motivation.
Daily monitoring of team performance and progress towards discharge plans and/ or need to alter discharge plan due to change in patient condition / family needs, with a priority placed on those patients at highest risk for complication/ admission/ readmission.
Develops collaborative relationships with the site patient care administrators, medical staff leadership, managed care contractors, and community leaders.
Ensures all patient care activities support established clinical standards of care and comply with various regulatory agencies and consider age specific, developmental, and cultural needs of the patient population served.
Promotes and models appropriate professional behavior as described in the Code of Conduct.
Demonstrates a passion for service excellence and commitment to “Patient First” goals.
Achieves results by developing strategies to manage patient care across the continuum, focusing on high risk, high cost, and problem prone areas to include patient at risk for re-admission.
Supports processes for clinical quality/ cost-improvement initiatives, preventing re-hospitalizations.
Builds and maintains effective partnership and relationships with other healthcare teams.
Conducts regular guidance and collaboration of team members.
Embraces, promotes, and communicates change.
Facilitates and supports team member involvement in professional and organizational activities.
Demonstrates professional accountability by maintaining proficiency in assigned role.
Holds self and others accountable to Orlando Health’s mission, vision, and values.
Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus, and evaluating outcomes of treatment options to include tracking patient progress towards care plan goals, and revising the care plan as indicated.
Advocates for patients in order to optimize their health care needs including but not limited to safety, physical, legal, and financial well-being.
Monitors completion and compliance of discharge assessments.
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
Maintains compliance with all Orlando Health policies and procedures.